Traumatic Renal Injury Research Articles

Comparative Analysis of Focused Assessment with Sonography for Trauma (Fast) and Computed Tomography (Ct) for Renal Injury Detection in Trauma Patients

OBJECTIVES This study aimed to evaluate the diagnostic accuracy of Focused Assessment with Sonography for Trauma (FAST) in detecting renal injuries compared to computed tomography (CT) as the gold standard. METHODOLOGY This cross-sectional study was conducted from 2022 to 2023 at the Department of Radiology, Khyber Teaching Hospital, Peshawar. The sample size was 139. The sonographic examination and computed tomography were performed. RESULTSThe mean age was 38 years ± 13.81. 100(72%) patients were male while 39(28%) were female. FAST had a sensitivity of 85%, specificity of 57.14%, positive predictive value of 97.42%, negative predictive value of 16.66%, and diagnostic accuracy of 83.61%. CONCLUSION FAST has reasonable sensitivity, specificity, and accuracy for detecting free fluid in traumatic renal injury patients.

Renal Trauma in an Adolescent of a Tertiary Care Hospital; Is Ultrasound Adequate?

Children are at high risk of renal injury from blunt trauma than adults. Renal trauma can be from direct, blunt, penetrating and iotrogenic injury. Renal injuries are accounting for 10% of abdominal trauma. In our cases, renal injury caused to patient after falling from bicycle in September 2023. Depending upon the pre-existing congenital or acquired renal pathology, its incidence increases. Blunt trauma comprises more than 95% of traumatic renal injury. Patient with renal trauma present with flank &/or abdominal pain and with hematuria. Computed tomography (CT) is the investigation of choice in evaluation of blunt renal injury. Ultrasound is helpful in detecting hemoperitonum in patients with suspected intraperitoneal injury. FAST (Fast Abdominal Sonography for Trauma), thus is important. Sonography was conducted to precisely diagnose and detect renal injuries caused by blunt abdominal trauma. Ultrasonography is also useful in detecting injuries and it is less value in evaluating those with suspected extraperitoneal injury. In some cases, MRI, Renal angiogram and scintigraphy may be useful. In our case, an adolescent boy with fall from bicycle sustaining blunt abdominal trauma in September 2023 with Gr-IV injury to right kidney is under observation as hemodynamically stable. No Pediatric renal trauma guidelines have been established though children are at higher risk of renal injury from blunt trauma than adults.

Management of Adult Blunt Renal Injury: A 10-Year Retrospective Review at a Single Institution

Purpose: Renal injury occurs in up to 5% of trauma cases and the kidney is the third most wounded abdominal organ. The study objective was to analyze clinical characteristics of patients with blunt renal trauma and review the treatment of high-grade blunt renal injuries.Methods: The medical charts of trauma patients who visited Haeundae Paik Hospital between March 2010 and February 2020 were retrospectively analyzed. Data on demographics, injury patterns, clinical presentation, management, and outcomes were analyzed.Results: A total of 68 patients with renal trauma were included in this study. The most common renal injury was Grade III (<i>n</i> = 27, 39.7%). Falling was the predominant mechanism of injury (<i>n</i> = 33, 48.5%), and 23.5% (<i>n</i> = 16) of patients sustained isolated renal trauma. Organ damage related to kidney injury included chest injury (57.4%, <i>n</i> = 39) and abdominal or pelvic content injury (48.5%, <i>n</i> = 33). The overall mortality rate was 2.9% (<i>n</i> = 2). There were 45 cases of high-grade renal trauma (AAST Kidney injury scale Grade Ш-V). There was no statistical difference in the outcomes of high-grade (<i>n</i> = 44, 97.8%) and low-grade (<i>n</i> = 23, 100%) renal trauma patients who received nonoperative treatment (<i>p</i> = 0.511). Variables did not differ significantly, except for the injury severity score which was statistically significantly different between low-grade and high-grade renal trauma patients (<i>p</i> = 0.001).Conclusion: Most patients with traumatic renal injury, even those with high-grade injury, can be managed by nonoperative treatment, and have a good prognosis.

Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma

BackgroundThe kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma.MethodsThe working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation.ResultsA total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends.ConclusionIn hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury.Level of evidence: Guideline; systematic review, level III.

Pattern and Severity of Traumatic Renal Injury: A Three-Year Study at Single Level One Trauma Center in Southern Iran

Background: Renal trauma is among the most important trauma challenges. Better management of traumatic renal patients is necessary to improve the patients’ clinical outcome. Objectives: This study aimed to analyze the pattern, severity, mechanism of injury, and outcome in renal trauma. Methods: This cross-sectional study was conducted in the largest trauma center in southern Iran from March 2018 to June 2022. Adult patients with diagnosed renal trauma based on abbreviated injury scale guideline were included. Variables of age, gender, anatomy of injury, mechanism of injury, lenghth of hospitalization, level of blood pressure, severity of injury, and the outcome of patients have been collected. Results: In total, 4,416 traumatic patients were admitted to the Emergency Department of the Hospital during the study time, of which 46 cases had traumatic renal injury. The rate of renal injury in the level one trauma center in southern Iran was 0.96%, and the death rate in renal injury victims was 12(26.1%). Most of the injured with renal injury were men 39(84.8%). Blunt trauma was the dominant type of trauma in most victims with renal injury 34(73.9%). Thirty-seven percent (n=17) of traumatic renal injury victim was in mild level (grade 1 and 2), and 16(34.8%) in severe level (grade 4 and 5). Renal injury was mostly associated with thorax injury (n=46) as extra-abdominal organ injury, and liver injury (n=16) and spleen (n=15) as intra-abdominal organ injury. Conclusion: The results of the present study showed that the severity of injury in patients with renal injury is high, and it is usually associated by injury to other body organs. It is suggested that the traumatic patients should be immediately examined for renal injury in the resuscitation department due to the high mortality rate and severity of these patients.

Resource utilization and secondary overtriage for patients with traumatic renal injuries in a regional trauma system.

While renal trauma management has shifted to conservative nonoperative management, insufficient data exist to guide interhospital renal trauma transfer protocols. Secondary overtriage is defined as the potentially avoidable transfer of patients from a lower to a higher-level trauma center despite the lack of need for higher-level care. The goal of this study was to determine the prevalence and predictors of secondary overtriage in renal trauma patients to a level 1 trauma center. A retrospective cohort study was performed of all renal trauma patients transferred to a level 1 institution between 2005 and 2017. Secondary overtriage was defined as a potentially avoidable transfer that consisted of hospital stay <72 hours with survival, no surgical or interventional radiology procedure, and all nonabdominal Abbreviated Injury Scale scores of <3 after transfer. Multivariate logistic regression was performed to estimate odds of secondary overtriage based on predefined clinical criteria. Of the 612 renal trauma patients transferred between 2005 and 2017, 71 (11.6%) met the criteria for secondary overtriage. Female patients and patients coming from level IV/V trauma centers were more likely to have potentially avoidable transfers (p = 0.01 and p < 0.001, respectively). Mean (SD) Injury Severity Score was 10 (4.2) and 30.7 (14.3) in overtriaged and appropriately triaged patients, respectively (p < 0.001). Of the 71 overtriaged patients, 70.4% had isolated renal injuries. Patients with isolated renal injuries (odds ratio, 39.0; 95% confidence interval, 16.44-105.39) and those transferred from a level IV/V trauma center (odds ratio, 3.85; 95% confidence interval, 1.64-9.61) had a higher likelihood of secondary overtriage. Within our regional trauma system, the majority of secondary overtriage was due to potentially avoidable transfers from level IV/V centers and of patients with isolated renal injuries. By implementing strategies to reduce the secondary overtriage burden on major trauma centers, regional trauma systems can avoid unnecessary costs while maintaining patient safety and ensuring appropriate care. Therapeutic/care management, Level III.

Evaluation of urinary extravasation after non-operative management of traumatic renal injury: a multi-center retrospective study

PurposeUrinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. The purpose of this study was to evaluate these factors in patients with traumatic renal injury.MethodsThis was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 h after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis.ResultsIn total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV–V (adjusted odds ratio, 33.8 [95% confidence interval 7.12–160], p < 0.001).ConclusionWe observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV–V injury were associated with having urinary extravasation.

A new biomarker (RENALASE) for the diagnosis of blunt renal trauma in an experimental study

Kidneys are the most frequently injured organ in the genitourinary system, but there is no specific biological marker for this trauma. Renalase may be a descriptive biomarker of the pathology that causes renal ischemia, nephrotoxicity, and acute renal failure. This study investigated the role of serum and urine levels of renalase for the diagnosis of renal injury in rats with experimentally induced blunt renal trauma. Thirty 3-month-old Sprague-Dawley adult male rats were divided into five groups (n=6) as follows: control (Group 1), sham (Group 2), right nephrectomy (Group 3), left renal trauma (Group 4), and right nephrectomy plus left renal trauma (Group 5). Serum samples were acquired 3, 24 and 48h post-trauma, and urine samples were acquired between 0-24 and 24-48h post-trauma. Changes in serum and urine levels of renalase, dopamine, epinephrine, metanephrine, normetanephrine, urea, and creatinine were assessed after blunt renal trauma. No significant changes in serum levels of these compounds were observed at 3h post-trauma in Groups 1 and 2 or in urine collected sequentially at 0-24 and 24-48h. By contrast, levels of renalase, dopamine, metanephrine, and normetanephrine in serum increased during hour 3 in Groups 4 and 5. Moreover, increases in urine levels of renalase, dopamine, epinephrine, metanephrine, and normetanephrine were observed at hours 0-24 in Groups 4 and 5. A definitive diagnosis of traumatic renal injury in children is made with contrast-enhanced computed tomography. However, the scan results in high doses of radiation exposure to children. Here, we report for the first time that renalase levels may be useful as a biomarker for the diagnosis of renal injury due to blunt renal trauma. Renalase may be a simple, effective, and noninvasive biomarker that indicates traumatic renal injury. It could be used as an adjunct for evaluation, particularly for isolated traumatic renal injury in cases where access to computed tomography is not straightforward.

High grade renal trauma: Does the mechanism of penetrating injury influence renal salvage rate?

BackgroundMost of the data on high grade Traumatic renal injuries (TRI) has come from centres which predominantly encounter blunt trauma. Blunt and penetrating mechanisms are not analogous, and it is imprudent to blindly extrapolate management strategies between the two groups. In addition, within the broad group of penetrating mechanisms of injury there are also major differences between gunshot wounds (GSW) and stab wounds (SW). The aim of this comparative study of GSW and SW to the kidney is to quantify the impact of the mechanism of injury on nephrectomy rate in high grade TRI. MethodsA prospective trauma registry was interrogated retrospectively. All patients sustaining a high grade (Grade III to V) penetrating TRI were included. The diagnosis was made either with cross-sectional imaging or intra-operative findings. The nephrectomy rate of the different mechanisms of penetrating (GSW vs SW) TRI was compared in each grade. ResultsA total of 28 GSW and 27 SW causing high grade TRIs (Grade III-V) were included over the 85 months of the study. GSW lead to a higher nephrectomy rate than SWs 50.0 vs 19%, (p = 0.023). When comparing grade for grade, Grade III: 20.0 (GSW) vs 21% (SW), (p = 1). Grade IV: 71 (GSW) vs 17%, (SW) (p = 0.058) and Grade V: 100 (GSW) vs 0%, (SW) (p = 0.28). When comparing Grade IV – V together, the difference is 85 (GSW) vs 15%, (SW) (p = 0.001). ConclusionOn a grade to grade comparison GSWs have a much higher risk for nephrectomy than SW's in grade IV and V TRI. TRI secondary to GSWs appears to be an independent risk factor for nephrectomy in high grade injuries. The mechanism of penetrating TRI should be considered in future management algorithms and clinical approaches.

Conservative management of grade 4 and 5 renal injuries: A high-volume trauma center experience.

Traumatic renal injuries represent a major public health issue concerning mostly young men. Over the last decades there is growing debate regarding the management of high-grade renal injuries due to the emerging role of conservative treatment. The aim of this study is to present our experience in the conservative management of patients presenting with grade 4 or grade 5 renal injuries in our department. In this retrospective, single center study we evaluated data from a total of 57 hemodynamically stable patients who were managed conservatively for grade 4 or grade 5 renal injuries from 2015 to 2019 in our high-volume trauma center. Grading was based on contrast enhanced abdominal computed tomography (CT) scans. Patients managed with immediate nephrectomy due to hemodynamic instability and patients who underwent immediate laparotomy due to concomitant injuries or penetrating wounds were excluded from the study. A total of 54 patients diagnosed either with grade 4 or grade 5 renal trauma were finally successfully managed conservatively and included in the study. Median age was 34 years. Most patients presented with grade 4 renal trauma while five patients presented with grade 5 renal injury. Concomitant injuries not requiring surgical intervention were present in 48 patients. Continuous renal bleeding was detected in 15 patients (27.8%) and subsequent arterial embolization was performed with no further intervention required. Urine leak was diagnosed in 12 patients treated either by double j stent or by nephrostomy tube. Grade 4 and selected cases of grade 5 renal trauma can be treated conservatively with close monitoring and CT scan protocols in hemodynamic stable patients. In cases of continuous bleeding, arterial embolization can be performed. In cases of severe urine leak conservative management is also feasible either by inserting a double j stent or a nephrostomy tube.

Independent predictors of mortality for patients with traumatic renal injury

To investigate the parameters of renal trauma, including emergent intervention type, that predict the mortality of patients with traumatic renal injury. A retrospective database analysis was performed on patients who sustained a traumatic renal parenchymal injury identified by the 2017 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, ER and hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score, renal injury grade, and need for emergent intervention (angioembolization versus open surgery). Logistic regression was used to correlate intervention type and trauma parameters to mortality. A total of 4,876 of 1,004,440 trauma patients (0.49%) had a traumatic renal injury. Of those, 220 (4.5%) underwent an emergent intervention-29 (0.59%) angioembolization and 191 (3.9%) open renal surgery. 83 patients with a blunt renal trauma (2.0%) underwent renal intervention, whereas 136 (21.0%) with a penetrating injury required a procedure. Forty-five of the 220 patients (20.5%) who had a renal intervention died, while 377 of 4,656 (8.1%) who did not have an intervention died. Multiple logistic regression identified black race, age > 45years, penetrating trauma, and ISS > 15 to be independent predictors of mortality. Neither angioembolization nor open renal surgery was associated with a significantly higher likelihood of mortality in the multivariable model. While procedural interventions are associated with higher mortality for patients with traumatic renal injury, other factors, such as race, age, trauma type, and injury severity may be more predictive of death under care.

Variation in management of pediatric post-traumatic urine leaks

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Renal artery angiography in pediatric trauma using a national data set

With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions. All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n=9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.

Interventional radiology in the management of renal vascular injury: A prospective study.

Introduction:Endovascular and percutaneous interventions are promising alternatives to surgical management of traumatic renal injuries and often avert the need for nephrectomies. In this study, we aimed to evaluate the role of interventional radiology and angiographic interventions in the management of renal vascular injury.Materials and Methods:Our prospective study was performed over a period of 6 months. Twenty-five patients who presented with either persistent hematuria or hemodynamic instability after traumatic or iatrogenic renal injuries were selected. Angiographic embolization using varying combinations of coils, glue, and Gelfoam® was performed to address the vascular injuries, either directly in hemodynamically unstable patients or after preprocedural imaging in hemodynamically stable patients. Patients were then followed up till discharge from hospital 48 h later and at 2 weeks and 4 weeks postprocedure for any recurrence of hematuria or hemodynamic instability. Technical and clinical success rates were calculated using descriptive statistics.Results:Pseudoaneurysms were the most common form of arterial injury (22 cases), followed by arteriovenous fistula (8) and active extravasation (5). Segmental arteries are the most commonly involved (12 cases), followed by interlobar (9) and arcuate (3) arteries. Gelfoam® was used in five patients with active contrast extravasation and was 100% effective in arresting active bleeding. Coiling alone had a 79.16% technical success rate in management, while additional use of glue in four failed cases led to a 95.83% technical success rate in the first attempt. The ultimate technical and clinical success rate of interventional radiology in renal trauma management (after the second attempt in one failed case) was 100%.Conclusion:Endovascular management is an effective and safe alternative to surgical management of both iatrogenic and accidental renal vascular injuries.

Traumatic renal injury: Five-year experience at a major trauma centre in South Africa

BackgroundThis study is intended to assess the current optimal management of traumatic renal injuries (TRIs), with a focus on high-grade and penetrating injuries. MethodsThe Pietermaritzburg Metropolitan Trauma Service registry was interrogated retrospectively for patients managed for TRI between 1 January 2012 and 31 December 2016. ResultsOf 13,315 inured patients treated by the PMTS, 223 (1.7%) had TRIs with an incidence of 1.5 per 100,000 population per year. The majority were males between 20 and 39 years of age. The distribution of mechanism of injury was 56.1% (n = 125) blunt and 43.9% (n = 98) penetrating trauma with no association between mechanism and grade of injury. Penetrating trauma was associated with hollow viscus and diaphragm injuries and blunt trauma with solid organ injuries. A total of 118 patients (52.9%) were managed non-operatively, 60 (26.9%) were not explored at operation, 27 (12.1%) underwent initial nephrectomy and 8 (3.6%) underwent renorraphy. Low-grade injuries (AAST I and II) and high-grade injuries (AAST III-V) were managed without renal intervention (non-operatively or not explored at laparotomy for associated injuries) in 88.7% (n = 87) and 72.0% (n = 91) of cases respectively. Blunt and penetrating injuries were managed without renal intervention in 87.9% (n = 109) and 70% (n = 69) of cases respectively. The initial nephrectomy rate was 1% (n = 1) and 20.6% (n = 26) for low- and high-grade injuries respectively, and 6.5% (n = 8) and 19% (n = 19) for blunt and penetrating injuries respectively. High grade (AAST III-V) injury (OR 14.94; 95% CI 3.36 – 66.34; p<0.001), penetrating mechanism (OR 4.99; 95% CI 1.98 – 12.52; p = 0.001) and metabolic acidosis (OR 2.73; 95% CI 1.04 – 7.20; p = 0.042) were significant risk factors for nephrectomy. Four patients (1.8%) underwent ureteral stent insertion and 2 (0.9%) underwent embolisation. The failure rate of initial non-operative management was 1.1%. The mortality rate was 8.1% (n = 18), but no patients with solitary renal injuries died. ConclusionEven in high-grade injuries and penetrating trauma, the majority of patients with TRI can be managed non-operatively or with the assistance of endourological or endovascular techniques, with good outcomes. Risk factors for nephrectomy include the presence of high-grade injuries, penetrating trauma and metabolic acidosis on presentation.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

An Unusual Complication of Colonic Perforation Following Percutaneous Nephrostomy in a Grade IV Blunt Renal Injury Patient

Percutaneous nephrostomy is relatively safe for temporary urinary diversion. However, colonic perforation due to percutaneous nephrostomy can happen with an incidence of 0.2% as reported in the English literatures. To our knowledge, this is the first case being reported as a complication following treatment for traumatic renal injury. This paper is to share our treatment approach which differs from the usual approach according to existing literatures. We report on a young man who sustained grade IV renal injury due to blunt trauma and was managed conservatively. The treatment of traumatic renal injury via urinary diversion was complicated with an iatrogenic colonic perforation. The management and subsequent treatment of this patient is discussed in this case report.

Trauma Audit for Intra-Abdominal Injury in Hospital Pulau Pinang

Introduction: Intra-abdominal injury is one of the leading causes of morbidity and mortality in all age groups in the world. Our aim is to review the demography, incidence rates and prevalence of intra-abdominal injury in Hospital Pulau Pinang in a tertiary hospital in Northern region of Malaysia. Materials and Methods: We retrospectively reviewed medical records of patients diagnosed with intra-abdominal injury from January 2016 until December 2017 using an in-house electronic database. Traumatic renal injury was excluded. Diagnosis was confirmed via contrast-enhanced CT scan or exploratory laparotomy. Results: A total of 82 patients were diagnosed with intraabdominal injury over a period of 2 years. There is a male (75.61%) and of Chinese ethnicity (43.90%) predominance. Median age at presentation was 20 years old. The oldest patient was 94 years old and the youngest patient was 9 months old. Commonest etiology was motor vehicle accident (78.04%) followed by traumatic fall (12.19%). The commonest injury was splenic injury (50%) followed by liver injury (39.28%). The majority of patient (59.52%) was treated non-surgically, in which a grade 2 splenic injury patient underwent operation after failing a non-operative management. There were only 2 mortalities among the 34 patients in the operative group. There is a higher incidence among Chinese ethnicity due to skewed distribution of Chinese population in our studied area in relation to total Chinese population in Malaysia. We showed a reduction in negative laparotomy in stable patients with suspected intra-abdominal injury with the utilization of a CT scan. Decision for non-operative management should be tailored to individualized approach accompanied by serial assessment for optimal care. Conclusion: Blunt trauma was the most common type of intra-abdominal injury and the spleen was found to be the most common organ injured.

Traumatic renal injury in a UK major trauma centre - current management strategies and the role of early re-imaging.

To analyse the contemporary management of renal injuries in a UK major trauma centre and to evaluate the utility and value of re-imaging. The prospectively maintained 'Trauma Audit and Research Network' database was interrogated to identify patients with urinary tract injuries between January 2014 and December 2017. Patients' records and imaging were reviewed to identify injury grades, interventions, outcomes, and follow-up. Renal injury was identified in 90 patients (79 males and 11 females). The mean (sd; range) age was 35.5(17.4; 1.5-94)years. Most of the renal traumas were caused by blunt mechanisms (74%). The overall severity of injuries was: 18 (20%) Grade I, 19 (21%) Grade II, 27 (30%) Grade III, 22 (24%) Grade IV, and four (4%) Grade V. Most patients (84%) were managed conservatively. Early intervention (<24h) was performed in 14 patients (16%) for renal injuries. Most of these patients were managed by interventional radiology techniques (nine of 14). Only two patients required an emergency nephrectomy, both of whom died from extensive polytrauma. In all, 19 patients underwent laparotomy for other injuries and did not require renal exploration. The overall 30-day mortality was 13%. Re-imaging was performed in 66% of patients at an average time of 3.4days from initial scan. The majority of re-imaging was planned (49 patients) and 12% of these scans demonstrated a relevant finding (urinoma, pseudoaneurysm) that altered management in three of the 49 patients (6.1%). Non-operative management is the mainstay for all grades of injury. Haemodynamic instability and persistent urine leak are primary indications for intervention. Open surgical management is uncommon. Repeat imaging after injury is advocated for stable patients with high-grade renal injuries (Grade III-V), although more research is needed to determine the optimal timing.

Long-term renal outcomes in patients with traumatic renal injury after nephrectomy: A nationwide cohort study

BackgroundThe long-term renal outcomes of patients who underwent nephrectomy for traumatic renal injury (TRI) have rarely been reported. Therefore, we investigated the impact of nephrectomy for TRI on long-term renal outcomes. Methods and materialsWe extracted data from the National Health Insurance Research Database (NHIRD) of Taiwan from 1999 to 2013 and identified patients with TRI. Adverse kidney outcomes (AKOs), including lifelong dialysis and chronic kidney disease (CKD), were chosen as endpoints of the study. ResultsA total of 16,320 eligible patients were identified in the NHIRD. The incidence of lifelong dialysis was 0.6% (99/15,789) for patients without nephrectomy, while the incidence was 1.1% (6/531) for nephrectomized patients. Overall, the incidence of AKOs was 2.1% (11/531) in the group that underwent nephrectomy and 1.1% (166/15,789) in the group without nephrectomy. Before matching, differences in overall AKO incidence between the groups were significant, while propensity score matching eliminated this significance. ConclusionsThe results of our study did not indicate that AKOs would occur in patients with TRI who underwent nephrectomy.